REGISTRO DOI: 10.69849/revistaft/cl10202411250647
Main Autor: Kamila Vasconcelos Neves Troper
Co-authors: Pedro Miguel Mestre
Ana Sofia Pinela
Ana Luísa Lima
Advisor: Teresa Martinho Valente
Affiliation: Hospital prof. Doutor Fernando Fonseca/Amadora-Sintra
RESUME
The concept of moral injury is believed to have first appeared in the literature in the 1990s in the context of combat and wartime circumstances, but has recently been brought more broadly into the health context. The term is often associated with strong moral emotions related to the event, including guilt, anger and disgust and can lead to distress and psychological difficulties could be significantly associated with Post-traumatic stress disorder , depression and others mental health disturbs. In occupational health, the concept has gained more recognition for discussion and consequent prevention. It can arise in different professions, not just health professionals, although they have a higher prevalence than other classes of worker. Due to the serious consequences for the mental health of health professionals, it is very important to recognize and give them some support.
Keywords: Occupational Moral Injury + Mental Health + Healthcare professionals.
Introduction
Moral injury is a relatively new concept in the literature. In recent decades it has become more widely used and better known.
As a concept, moral injury first appeared in the literature in the 1990s(5) in the context of combat and war circumstances – however, it has recently been brought up more broadly in the healthcare context.(6,7,8)
Drescher et al. (2011) define moral injury as “disruption in an individual’s confidence and expectations about one’s own or others’ motivation or capacity to behave in a just and ethical manner”(9)
Moral injury is often associated with strong moral emotions related to the event, including guilt, anger and disgust(2)and can lead to distress and psychological difficulties.
‘Moral injury’ arises from the ‘moral distress’ that individuals feel when constrained from doing what they believe is the right thing by external factors, such as re source availability. Moral distress upon moral distress, with limited time to process what has happened, reduces tolerance for further moral dilemmas. This build-up of ‘moral residue’, those niggling doubts about the finely balanced decisions made, can result in moral injury— Epstein and Hamric dubbed this the ‘crescendo effect’ (12,13). This theory leads us to suggest three key prevent a tive strategies: enhanced decision-making support with complex decisions shared; the provision of time and space for clinicians to ‘decompress’; and staff working consistently within the same team.(12)
Moral injury is significantly associated with Post-traumatic stress disorder (PTSD) and depression. Studies have shown that potentially morally injurious events (PMIEs) account for a notable variance in PTSD and depression symptoms among affected individuals(1, 15, 16).
In occupational health, the concept has gained more recognition for possible discussion and consequent prevention. It can appear in different professions, not just health professionals, although they have a higher prevalence than other classes of worker who may even have some related situation during their professional experience. It is a new concept within occupational health and needs to be better understood.
Certain occupational groups may be at risk of exposure to work-related morally injurious events, including first responders, journalists and armed forces personnel.(1)
Healthcare workers, particularly during the COVID-19 pandemic, have reported high levels of PTSD and depression linked to moral injury, exacerbated by factors such as lack of personal protective equipment (PPE) and high patient mortality rates(14, 17).
Exposure to the situation among health professionals can be enormous, especially in some occupations and specialties where the professional has to make important decisions about the patient’s life. Discussing the possibility of this happening can help avoid the problem and bring a better quality of life to workers, as well as reducing the permanent consequences that can result from moral injury.
Objectives
Main: To carry out a comprehensive review of the literature on the effect of professional moral injury on the mental health of healthcare personnel.
Secondary: To understand the concept of professional moral injury.
Material and Methods
Systematic literature review using databases with the descriptors. Studies published between 2000 and 2023 in Portuguese, English and Spanish.
The methodology used to construct the comprehensive literature review was subdivided into search methods and selection criteria.
Regarding the search methods:
The descriptors used were: Occupational Moral Injury + Mental Health + Healthcare professionals.
The databases used to search for the studies were, in order of use:
1)Google Scholar
1)Pubmed
2)Research Gate
3)ScienOpen
4)International Occupational Health and Safety Database
Regarding the selection criteria used:
Most of the studies selected were English language articles published between 2000 and 2023 in the main databases described above.
The review looked for studies that focused primarily on the relationship between the concept of moral injury + the mental health of health professionals. Studies that tended to approach the concept of Moral Injury from other areas were excluded, such as causes that were purely family related, prevention methods that were not used in the work context, or causes that were linked to personal backgrounds that were not related to professional origin, or even describing more religious issues.
A small number of six (6) studies were excluded due to access difficulties. Studies published before the period established in the selection were also excluded because they used methodologies that are sometimes less common today, as well as because of the long time interval in relation to the bibliographical references used.
Results
Of the 354 (three hundred and fifty-four) studies initially found in the aforementioned databases, a sample of 33 (thirty-three) studies that met the selection criteria was obtained. After a final review, a final sample of 11 (eleven) studies, mostly articles, was defined according to the pre-established criteria and access to the studies. Studies that were not related to health professionals or that did not deal with mental disorders were mainly excluded.
| ARTICLE | AUTHORS | JOURNAL | YEAR | RESULTS |
| Moral injury in secure mental healthcare part II | Morris, D., Webb, E., & Devlin, P. | The Journal of Forensic Psychiatry & Psychology | 2022 | Moral injury predicted higher secondary trauma and burnout, and lower compassion satisfaction. |
| Moral injury in medicine: recognition and guidance | Kok, H., Hoedemaekers, C., Zegers, M., & Gurp, J. | Nederlands tijdschrift voor geneeskunde | 2023 | Physicians can experience moral injury when acting in ways that conflict with their deep-held moral beliefs, especially during times of scarcity and resource constraints. |
| Healthcare Workers and COVID-19-Related Moral Injury. | D’Alessandro, A., Ritchie, K., McCabe, R., Lanius, R., Heber, A., Smith, P., Malain, A., Schielke, H., O’Connor, C., Hosseiny, F., Rodrigues, S., & McKinnon, M. | Frontiers in Psychiatry | 2022 | Interventions targeting social support, acknowledgment, and exclusion can help prevent and treat COVID-19-related moral injury in healthcare workers. |
| Moral injury and psychological wellbeing in UK healthcare | Williamson, V., Lamb, D., Hotopf, M., Raine, R., Stevelink, S., Wessely, S., Docherty, M., Madan, I., Murphy, D., & Greenberg, N. | Journal of Mental Health | 2022 | Moral injury experiences during the COVID-19 pandemic significantly impacted the mental health of healthcare staff, with specific work factors like redeployment and colleague deaths being significant contributors. |
| Examining moral injury in clinical practice: A narrative literature review. | Mewborn, E., Fingerhood, M., Johanson, L., & Hughes, V. | Nursing Ethics | 2023 | Moral injury in healthcare is caused by systemic factors, such as administrative burden, institutional betrayal, lack of autonomy, and inadequate resources, leading to burnout, job abandonment, and post-traumatic stress. |
| Moral Injury | Shay, J. | Intertexts | 2012 | Moral injury impairs trust and increases despair, suicidality, and interpersonal violence, requiring a trustworthy clinical community and well-functioning team for successful outcomes. |
| Occupational moral injury and mental health | Williamson, V., Stevelink, S. A., & Greenberg, N. | The British Journal of Psychiatry | 2018 | Occupational moral injury is associated with increased PTSD, depression, and suicidality, but more research is needed on civilian populations. |
| Physicians aren’t ‘burning out.’They’re suffering from moral injury | Talbot, S. G., & Dean, W. | Stat | 2018 | Moral injury is frequently mischaracterized. In combat veterans it is diagnosed as post-traumatic stress; among physicians it’s portrayed as burnout. |
| It’s time to talk about physician burnout and moral injury | Kopacz, M. S., Ames, D., & Koenig, H. G. | The Lancet Psychiatry | 2019 | Moral injury constitutes a substantial source of mental health morbidity, the result of having transgressed or violated core moral boundaries. |
| Moral injury in healthcare professionals | Čartolovni, A., Stolt, M., Scott, P. A., & Suhonen, R. | Nursing ethics | 2021 | Moral injury in healthcare professionals is a deep emotional wound experienced by those who witness intense human suffering and cruelty, and may turn into moral residue and moral injury over time in certain circumstances and contexts. |
| Moral Injuries in Healthcare Workers: What Causes Them and What to Do About Them? | Rabin, S., Kika, N., Lamb, D., Murphy, D., Stevelink, S., Williamson, V., Wessely, S., & Greenberg, N. | ournal of Healthcare Leadership | 2023 | Moral injury in healthcare workers can be reduced through pre-exposure mitigation and post-exposure mitigation, such as fostering work environments that treat morally injurious events as occupational hazards. |
Discussions
Most of the studies found in the literature were specific to the COVID-19 pandemic. This idea was not the aim of this work, apart from the increase in potentially morally injurious events (PMIEs) for healthcare, especially at this time. However, 2 (two) studies related to the time of the pandemic were included because of their importance and strong association with the main idea of the review. Given the enormous impact of the COVID-19 pandemic on the mental health of healthcare workers, it would be difficult not to include related studies.
The most common disorders found in the mental health of health workers in the context of moral injury were related to an increase in PTSD, depression and suicidality. In addition, it can also predict greater secondary trauma and burnout. The latter concept, burnout, needs to be distinguished from moral injury and characterised in order to avoid other important and even permanent mental health problems.
Other studies that met all the selection criteria and had the same aim were not included in this review because they were difficult to access. Others were not included because they did not meet all the defined criteria. Most of them were related to other professional groups.
Most of the included articles presented the concept of the importance of discussing mental health in healthcare sector.
Conclusions
Morally injurious experiences include those in which the individual perpetuates, fails to prevent, bears witness to, or learns about acts that transgress deeply held moral beliefs and experiences (3,4)
The mental health of health professionals who have suffered some kind of damage related to the concept in question needs some kind of support, and this support cannot take a long time to improve over a period of time that is not too short to work on.
Other concepts, such as Burnout, need to be identified and differentiated. This problem can be linked to and can originate after moral damage and can have serious consequences for the entire working class.
Moral injury can contribute to inner conflict and emotional distress and the emergence of guilt, shame, and anxiety is facilitated by idiographic factors such as shame proneness and/or neuroticism.(8)
If nothing is done to improve the mental health of health professionals, the negative consequence can be perpetuated for a long time for employees and not only, but for employers and society as a whole.
Bibliographic References
1) Williamson, V., Stevelink, S. A., & Greenberg, N. (2018). Occupational moral injury and mental health: systematic review and meta-analysis. The British Journal of Psychiatry, 212(6), 339-346.
2) Farnsworth, J. K., Drescher, K. D., Nieuwsma, J. A., Walser, R. B., & Currier, J. M. (2014). The role of moral emotions in military trauma: Implications for the study and treatment of moral injury. Review of General Psychology, 18(4), 249-262.
3) Litz, B., Stein, N., Delaney, E., Lebowitz, L., Nash, W. P., Silva, C., & Maguen, S. (2009). Moral injury and moral repair in war veterans: A preliminary model and intervention strategy. Clinical Psychology Review, 29, 695-706.
4) Bryan, C. J., Bryan, A. O., Anestis, M. D., Anestis, J. C., Green, B. A., Etienne, N., … & Ray-Sannerud, B. (2016). Measuring moral injury: Psychometric properties of the moral injury events scale in two military samples. Assessment, 23(5), 557-570.
5) Shay, J. (2010). Achilles in Vietnam: Combat trauma and the undoing of character. Simon and Schuster.
6) Talbot, S. G., & Dean, W. (2018). Physicians aren’t ‘burning out.’They’re suffering from moral injury. Stat, 7(26), 18.
7) Kopacz, M. S., Ames, D., & Koenig, H. G. (2019). It’s time to talk about physician burnout and moral injury. The Lancet. Psychiatry, 6(11), e28.
8) Čartolovni, A., Stolt, M., Scott, P. A., & Suhonen, R. (2021). Moral injury in healthcare professionals: a scoping review and discussion. Nursing ethics, 0969733020966776.
9) Drescher, K. D., Foy, D. W., Kelly, C., Leshner, A., Schutz, K., & Litz, B. (2011). An exploration of the viability and usefulness of the construct of moral injury in war veterans. Traumatology, 17(1), 8-13.
10) Williamson, V., Murphy, D., Stevelink, S. A., Jones, E., Allen, S., & Greenberg, N. (2023). Family and occupational functioning following military trauma exposure and moral injury. BMJ Mil Health, 169(3), 205-211.
11) Mantri, S., Lawson, J. M., Wang, Z., & Koenig, H. G. (2020). Identifying moral injury in healthcare professionals: the moral injury symptom scale-HP. Journal of religion and health, 59(5), 2323-2340.
12) Roycroft, M., Wilkes, D., Pattani, S., Fleming, S., & Olsson-Brown, A. (2020). Limiting moral injury in healthcare professionals during the COVID-19 pandemic. Occupational Medicine, 70(5), 312-314.
13) Epstein, E. G., & Hamric, A. B. (2009). Moral distress, moral residue, and the crescendo effect. The Journal of clinical ethics, 20(4), 330-342.
14) Rabin, S., Kika, N., Lamb, D., Murphy, D., Stevelink, S., Williamson, V., Wessely, S., & Greenberg, N. (2023). Moral Injuries in Healthcare Workers: What Causes Them and What to Do About Them?. Journal of Healthcare Leadership, 15, 153 – 160.
15) Williamson, V., Murphy, D., Phelps, A., Forbes, D., & Greenberg, N. (2021). Moral injury: the effect on mental health and implications for treatment.. The lancet. Psychiatry.
16) Hall, N., Everson, A., Billingsley, M., & Miller, M. (2021). Moral Injury, Mental Health, and Behavioral Health Outcomes: A Systematic Review of the Literature.. Clinical psychology & psychotherapy.
17)Williamson, V., Lamb, D., Hotopf, M., Raine, R., Stevelink, S., Wessely, S., Docherty, M., Madan, I., Murphy, D., & Greenberg, N. (2022). Moral injury and psychological wellbeing in UK healthcare staff. Journal of Mental Health, 32, 890 – 898.